Do not get biopsy without it !!!!

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cooper360
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Date Joined Jul 2010
Total Posts : 161
   Posted 11/11/2010 1:07 PM (GMT -6)   
I'm going to post this once a month for any new guys! I believe from the bottom of my heart no man should have a biopsy without it being color doppler guided. If you have to travel so be it,if you have to pay the difference between reg. & color pay it,for that matter if you have to pay period, pay it! This is speaking from a middle class, steel working family. There are a few areas in the country where there are excellent Dr's who can provide this kind of guided biopsy. You have the assurance of the doctor and yourself [you watch the ultrasound yourself w/wife or partner]. I cannot imagine starting down this path [with all its pitfalls] without it. Its one of those things when you experience it you know its right,not just for yourself but for all. For all who will say that's a broad statement, I say why not!!!!!...........That's my public service announcement......Cooper

Gregz263
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Date Joined May 2010
Total Posts : 133
   Posted 11/11/2010 1:35 PM (GMT -6)   
Totally agree.  Well said Cooper!
Greg
PSA 1/06 at age 40 = 1.0
PSA 4/09 at age 43 = 2.9

PSA 4/10 at age 44 = 4.6

FPSA 4/10 = 4.7 and 6%
10/10 = 4.7 and 9%

Biopsy 5/11/10 12 out of 12 negative
2nd Biopsy 7/13/10 12 out of 12 negative

Fairwind
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Date Joined Jul 2010
Total Posts : 2346
   Posted 11/11/2010 1:41 PM (GMT -6)   
Be that as it may, 95% of the biopsies will be performed without the extra guidance provided by the Color Doppler machine..

The end result is pretty much the same..They will find cancer or they won't..
Age 68.
PSA at age 55: 3.5, DRE normal. Advice, "Keep an eye on it".
age 58: 4.5
age 61: 5.2
age 64: 7.5, DRE "Abnormal"
age 65: 8.5, " normal", biopsy, 12 core, negative...
age 66 9.0 "normal", 2ed biopsy, negative, BPH, Proscar
age 67 4.5 DRE "normal"
age 68 7.0 third biopsy positive, 4 out of 12, G-6,7, 9
RRP Sept 3 2010, pos margin, one pos vesicle nodes neg. Post Op PSA 0.9

Casey59
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Date Joined Sep 2009
Total Posts : 3172
   Posted 11/11/2010 2:32 PM (GMT -6)   

CDU is a value-added step for anyone starting an Active Surveillance program.

For most guys planning surgery (for example, which is the most common treatment mode), not so important.


Tony Crispino
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Date Joined Dec 2006
Total Posts : 7665
   Posted 11/11/2010 2:49 PM (GMT -6)   
CDU is an enhancement and not a replacement for core biopsies. It is not a perfect method by any means. Attached is a comparative study posted at the InfoLink on CDU:

prostatecancerinfolink.net/2010/07/09/color-doppler-ultrasound-and-prostate-cancer-biopsy/

The study does show a failure rate of the technology to discover cancer that a TRUS biopsy detected of about 15%. Conversely, it detected prostate cancer in 27% of cases that a TRUS biopsy only detected 24%.

What I believe is missing in the study is whether has any ability to detect if the cancer has left the prostate. It is certainly possible with both technologies but we don't know if CDU improves that ability. Some say it does but there is no hard proof of it.

Is this the needed replacement for detecting prostate cancer? I don't think so. But it may be helpful for those who have had multiple TRUS biopsies come up negative. But again, a 15% failure rate to detect what a TRUS biopsy could leaves much to be desired. Hopefully further advances will improve this technology.

Tony
Disease:
Advanced Prostate Cancer at age 44 (I am 48 now)
pT3b,N0,Mx (original PSA was 19.8) EPE, PM, SVI. Gleason 4+3=7

Treatments:
RALP ~ 2/17/2007 at the City of Hope near Los Angeles.
Adjuvant Radiation Therapy ~ IMRT Completed 8/07
Adjuvant Hormone Therapy ~ 28 months on Casodex and Lupron.

Status:
"I beat up this disease and took its lunch money! I am in remission."
I am currently not being treated, but I do have regular oncology visits.
I am the president of an UsTOO chapter in Las Vegas

Blog : www.caringbridge.org/visit/tonycrispino

Post Edited (TC-LasVegas) : 11/13/2010 5:57:55 PM (GMT-7)


cooper360
Regular Member


Date Joined Jul 2010
Total Posts : 161
   Posted 11/11/2010 4:37 PM (GMT -6)   
I believe the doctor reading the CDU has alot [most] to do with how reliable this technology is. There are only a handful of doctors that have the equipment and the expertise to accurately sort out where to biopsy or even if to biopsy [in my husbands case] My husband experienced it and I sat right next to him and saw exactly what was on the screen the Dr saw calcification,prostatitis but no areas that needed further examination. If he had, then biopsy would have been done.   Cooper

Tony Crispino
Veteran Member


Date Joined Dec 2006
Total Posts : 7665
   Posted 11/11/2010 4:56 PM (GMT -6)   
I agree with that cooper.
The doctor does indeed matter for anything specialized. But we don't know the quality of the doctors in the study. Lee and Bahn claim to be the best and I think they probably are in the US, but we don't have much to compare with them. Both treat prostate cancer in a way that does not verify actual extensiveness of prostate cancer. And I don't know of many cases that saw them for CDU and had surgery. They will typically recommend cryo or radiation. PCRI, for which both are Scientific Advisory Board Members, tends to be radiation centric. Radiation will never provide actual comparative data on the performance of CDU or TRUS biopsy that removing the prostate and examining it will. But certainly if we can get a stronger imaging diagnostic, it will be helpful for all treated for prostate cancer. CDU is not new but there are a few places to get one done. There is a role for it for sure in prostate cancer.

Tony
Disease:
Advanced Prostate Cancer at age 44 (I am 48 now)
pT3b,N0,Mx (original PSA was 19.8) EPE, PM, SVI. Gleason 4+3=7

Treatments:
RALP ~ 2/17/2007 at the City of Hope near Los Angeles.
Adjuvant Radiation Therapy ~ IMRT Completed 8/07
Adjuvant Hormone Therapy ~ 28 months on Casodex and Lupron.

Status:
"I beat up this disease and took its lunch money! I am in remission."
I am currently not being treated, but I do have regular oncology visits.
I am the president of an UsTOO chapter in Las Vegas

Blog : www.caringbridge.org/visit/tonycrispino

Worried Guy
Veteran Member


Date Joined Jul 2009
Total Posts : 3246
   Posted 11/12/2010 10:58 PM (GMT -6)   
Sadly, my prostate was so rotten he would have needed CDU to find a spot that was normal!
I didn't have the CDU but my biopsy was still 7 out of 12. Lucky me.
Jeff

fulltlt
Regular Member


Date Joined Nov 2010
Total Posts : 190
   Posted 11/13/2010 11:35 AM (GMT -6)   
I have been told that the rectal biopsies regardless of color doppler or whatever can miss sampling 40% of the prostate. If you want a true analysis get an STPB.

142
Forum Moderator


Date Joined Jan 2010
Total Posts : 5902
   Posted 11/13/2010 12:34 PM (GMT -6)   
Had to look that one up - STPB.
Looks like (from the summaries on PubMed.gov) it is expected as a tool for re-biopsy, to get to the areas that a normal trans-rectal can not get to, when there are other indications that they missed something in the first biopsy.
The downside is that it is described as a general anesthetic procedure.
Hate to think the fight that would result with the insurance company -
 
My "normal", non CDU biopsy found more than I wanted to know about, so that was enough for me.
 

zufus
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Date Joined Dec 2008
Total Posts : 3137
   Posted 11/13/2010 1:47 PM (GMT -6)   
I find it also interesting the Dr. Bob B. (Michigan uro-surgeon and a great overall doc and person), will occassionally send his patients to get the nearby services from Dr. Fred Lee using CDU for biopsies or rebiopsies or comparisons. He is righteous enough, that it isn't all about his profit line for motivation purposes, more about what might serve the patient best. (that is why it is interesting).

So, CDU being used by the few whom devoted themselves to using it as artists are probably worthwhile for ones consideration. Plus you get to see the photo images.....horray.....'the colors'...(well Timothy Leary would have been impressed-LOL).
Dx-2002 total urinary blockage, bPsa 46.6 12/12 biopsies all loaded 75-95% vol.; Gleasons scores 7,8,9's (2-sets), gland size 35, ct and bone scans look clear- ADT3 5 months prior to radiations neutron/photon 2-machines, cont'd. ADT3, quit after 2 yrs. switched to DES 1-mg, off 1+ yr., controlled well, resumed, used intermittently, resumed useage

RCS
Veteran Member


Date Joined Dec 2009
Total Posts : 611
   Posted 11/13/2010 5:33 PM (GMT -6)   
Tony,

I can understand why the CDU detects cancer in 27% of the cases where TRUS biopsies did not detect (the needles missed the cancer).

What I do not understand is why the Trus biopsy detects cancer in 15% of the cases where the CDU did not detect cancer. Were the cancer tumors too small for the CDU to detect? What is the lower resolution of a CDU (1 mm?).
PSA 2007 - 2.8; 11/24/2008 - 7.6; PCa Dx 2/11/09; age at Dx 62; RLP 4/20/09

Biopsy - Invasive moderately differentiated prostatic andenocarconoma; G 3+3=6; PT2C; No evidence of Seminal Vesicle or Extraprostatic Involvement; Margins clear; Tumor identified in sections from prostatic apex. 70 gram prostate. Continent after removal of cath.

ED - Trimix works well; levitra @ 90%
PSA - 7/31/09 <0.06; 12/1/09 <0.06; 3/29/10 <0.06; 8/4/10 <0.06

Tony Crispino
Veteran Member


Date Joined Dec 2006
Total Posts : 7665
   Posted 11/13/2010 7:53 PM (GMT -6)   
RCS,
I can't answer that question. The study does not touch on that. It could be that not all cancers are going to show up on the screen, and logically we know that no imaging that we have today can detect prostate cancer when it's too small to see. CDU does give us a better approach but it's not strong enough to rely on it solely. I think the benefits outweigh the limitations, however. Cooper posted that all should use the technology however I don't think all will benefit from the use of it. I've seen where some members have used it here and their doctor saw what he thought was cancer only to have a negative biopsy. I would tell that patient that he still needs to be monitoring his PSA closely. Since CDU misses 15% that was detected by TRUS biopsy in the linked study, then it would be reasonable to suggest that it's possible that this is a missed detection case.

BTW I misinterpreted the study a bit. The CDU detected cancer in 27% of the cases while TRUS biopsy detected it in 24% of the cases. This is a very narrow gap.

Tony
Disease:
Advanced Prostate Cancer at age 44 (I am 48 now)
pT3b,N0,Mx (original PSA was 19.8) EPE, PM, SVI. Gleason 4+3=7

Treatments:
RALP ~ 2/17/2007 at the City of Hope near Los Angeles.
Adjuvant Radiation Therapy ~ IMRT Completed 8/07
Adjuvant Hormone Therapy ~ 28 months on Casodex and Lupron.

Status:
"I beat up this disease and took its lunch money! I am in remission."
I am currently not being treated, but I do have regular oncology visits.
I am the president of an UsTOO chapter in Las Vegas

Blog : www.caringbridge.org/visit/tonycrispino

Post Edited (TC-LasVegas) : 11/13/2010 5:59:58 PM (GMT-7)


Herophilus
Regular Member


Date Joined Sep 2009
Total Posts : 478
   Posted 11/14/2010 9:36 AM (GMT -6)   
First off, Cooper thanks for the interesting topic...
When I had my biopsy the physician used a “TargetScan” proprietary system. Its a 3D thing. I only know this as I am interested in such stuff and noted the name on the equipment while I was awaiting the team to do my biopsy. Then when I had the time I googled it. In my case, I had 10 of 12 positive, my brother with the same physician and technique, had 6 of 12 positive. This correlated nicely with the post-op path results as my brother had less cancer volume.
IMO…not having a biopsy based on the results of any type of imaging study is flawed. CT,MR, Ultrasound, CDU, or the human eye…the assumption that cancer, (prostate, can use other types of tissue here) is always a local or focal event in genesis is again in my opinion flawed. And think about this...If a physician postoperative can cut a prostate in half and actually look at the tissue, and touch the tissue and smell the tissue, can she or he say with absolute authority that the tissue is or is not cancerous? I know of a person that had a ugly looking tumor come out of his colon, the physician said as much ( this is probably going to be problem ,however we need to get the pathology report back before we know for sure). Just in the past few days a friend had the same conversation regarding a breast tumor that she had removed. However, an intra-operative “frozen section” provided a conclusive diagnosis. But the story is the same… You can’t tell by just looking at the tissue… the only way to make or exclude the diagnosis of cancer is with appropriate pathology examination. In some cases noted on this forum, even the microscopy observations vary between pathologist (is it cancer, is it not cancer) It’s biopsy for my family…I’m just saying….

Hero
Age 51 PSA 6.8
Bxy 10 of 12 Cores positive for Gleason 6. up to 75%
Robotic surg 11-02-09
Post op path. 20% neoplasm;4+3=7 Gleason
All nodes (14) and other related tissue negative for cancer
No EPE
Post op PSA x 3, all <0.01

fulltlt
Regular Member


Date Joined Nov 2010
Total Posts : 190
   Posted 11/14/2010 10:12 AM (GMT -6)   
142 said...
Had to look that one up - STPB.
Looks like (from the summaries on PubMed.gov) it is expected as a tool for re-biopsy, to get to the areas that a normal trans-rectal can not get to, when there are other indications that they missed something in the first biopsy.

The downside is that it is described as a general anesthetic procedure.

Hate to think the fight that would result with the insurance company -



My "normal", non CDU biopsy found more than I wanted to know about, so that was enough for me.



There's a video about STPB at:
http://chicagoprostate.wordpress.com/

Scroll down. It's near the bottom.

I have never had any problem with general anesthetic procedures. Insurance has covered all of them in the past.

goodlife
Veteran Member


Date Joined May 2009
Total Posts : 2621
   Posted 11/14/2010 5:03 PM (GMT -6)   
I would readily agree that color doppler is a great tool. I think we have seen where it is particlularly useful in finding PC where the TRUS doesn't, when the tumor is transitional or in a place where the needles may not hit it.

On the other hand, being a "garden variety" PC case, it really wasn't needed or useful in my case. Once the old needle hits some Gleason 7, 8, or 9, you most likely are going to the next step, particularly with a low PSA. In higher PSA's, it may be useful in determining if it has escaped the capsule yet, but most likely even the CDU woun't see a few cells outside the capsule.

I proceeded directly to the next step, no more diagnosis required, so why waste the time and money ? Seemed pointless in my case.
Goodlife
 
Age 58, PSA 4.47 Biopsy - 2/12 cores , Gleason 4 + 5 = 9
Da Vinci, Cleveland Clinic  4/14/09   Nerves spared, but carved up a little.
0/23 lymph nodes involved  pT3a NO MX
Catheter and 2 stints in ureters for 2 weeks .
Neg Margins, bladder neck negative
Living the Good Life, cancer free  6 week PSA  <.03
3 month PSA <.01 (different lab)
5 month PSA <.03 (undetectable)
6 Month PSA <.01
1 pad a day, no progress on ED.  Trimix injection
No pads, 1/1/10,  9 month PSA < .01
1 year psa (364 days) .01
15 month PSA <.01

cooper360
Regular Member


Date Joined Jul 2010
Total Posts : 161
   Posted 11/21/2010 11:21 AM (GMT -6)   
I see some new guys on here looking for what kind of biopsy to get IMO... Color Doppler guided seems best to me & a few others on here [JohnT being one]! Just bumping it up for Nov........................Cooper  wink

John T
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Date Joined Nov 2008
Total Posts : 3730
   Posted 11/21/2010 12:52 PM (GMT -6)   
A couple of things about Color Doppler.
Yes it does miss some cancers, but the CDU experts say that these are the clinical insignificant cancers that a random biopsy will sometimes pick up. Missing these is a good thing not a bad thing. They say that a CDU will identify those cancers that will hurt you a much higher % of the time than a random biopsy because all agressive tumors need blood flow to support them.
The real impact of CDU is in staging. It can identify tumor size and location. I believe many failed surgeries are due to the fact that the tumor had already penetrated the capsul or it was a large Apex or anterior tumor, or was near the nerves or seminal vessicles. All of these locations lead to a high surgical failure rate and it would be good for patients to know this before making a life changing decision.
In my own personal situation a CDU picked up a very agressive tumor that 13 random biopsies missed and also could not see a <5% G6 that the random biopsy picked up. The spot was rebiopsied with 3 cores and negative results. In this light it could help some patients avoid a radical treatment. It also identifies the tumor location as highly likely for a positive surgical margin. I recieved three important pieces of information from a CDU that were never available with a standard biopsy and contributed to my treatment decision making. I think its value is consistantly understated and everyone that I have talked to that has had a CDU was more than pleased they had done it.
JT
65 years old, rising psa for 10 years from 4 to 40; 12 biopsies and MRIS all negative. Oct 2009 DXed with G6 <5%. Color Doppler biopsy found 2.5 cm G4+3. Combidex clear. Seeds and IMRT, no side affects and psa .1 at 1.5 years.

cooper360
Regular Member


Date Joined Jul 2010
Total Posts : 161
   Posted 11/21/2010 3:54 PM (GMT -6)   
As always, very well said..................Cooper

compiler
Veteran Member


Date Joined Nov 2009
Total Posts : 5217
   Posted 11/21/2010 5:51 PM (GMT -6)   
John T., et. al.:
 
I got a question about CDU. I keep reading what a great thing this is. Yet, when I brought it up to my doctor about 15 months ago, I was told that it is way overhyped and not generally accepted as a big improvement.
 
This still seems to be the case. ie: it is not yet in the mainstream. As evidence, I keep hearing about the same 2-3-4 physicians who are using it. Why is that? If it is such a major improvement, why isn't this commonplace and considered state of the art?
 
Mel

Fairwind
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Date Joined Jul 2010
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   Posted 11/21/2010 8:27 PM (GMT -6)   
CDU can not identify cancer...It can, in expert hands, provide an assessment of risk of whether cancer might be lurking and point out where if might be..Many men are very gun-shy of biopsies and this instrument can help avoid needless ones by pretty much ruling out the presents of increased blood-flow aggressive tumors need.. If nothing else, they provide the patient some reassurance that a biopsy is really necessary and the urologist is not simply going on a fishing expedition...

Since doing biopsies is a profit center for Urologists, and they can lead to bigger things, they are not highly motivated to buy an expensive machine so they can do fewer biopsies..But with all the controversy boiling up now about excessive testing and unnecessary treatment, they may become more motivated when the U-doc down the street buys one..Back-stage, Medicare payments play an important part, as they always do..

John T
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Date Joined Nov 2008
Total Posts : 3730
   Posted 11/22/2010 12:24 PM (GMT -6)   
Mel,
this is the way it has been explained to me: CDU is very old technology even though it has had some recent improvements such as increased power range. It takes quite a bit of time and skill in order to learn how to accurrately read it. Most new radiadiology doctors are interested in the sexier newer technology and just don't want to put in the time learning an old technology. Most of the CDU doctors are old school.
The color doppler machines cost over $120,000 and urologists are not willing to invest in specialized equipment.
There is also a very vicious inside fight in that urologists think that the practice of giving biopsies should only be done by urologists and don't feel that radiologists should be giving biopsies. Dr Barantsz in Holland explained that every time he has attempted to develop a scan that would improve the accurracy of biopsies, he has be fought tooth and nail by the urologists. If the current gate keepers (urologists) of prostate cancer lose this position it's billions of dollars in revenue. Prostate Cancer is still the only cancer that has surgeons as the main diagnosticians.
Currently CDU is used only by interventional radiologists, and this is a very limited field. Even though I was a very special diagonostic case, none of my "expert" urologists ever mentioned CDU and when I finally said something they said it wouldn't work. Even when I did it against their recommendations and was discussing the results with my surgeon he was insisting that I should get an MRIS, which I already had that was negative. This is when the light went on and I realized that he was more interested in defending his position than in my welfare so I dropped him.
All I know is that I had 13 biopsies and an MRIS that were negative. I had two color dopplers that clearly showed a large tumor that was confirmed by biopsy and a Combidex scan. To me this was compelling evidence that two scans not supported by the urological community were much better than what they were using. The only way you would ever hear of the CDU is in forums such as this one or if you go to a private practice oncologist or a radiology center like Dattoli.
I know of about 5 doctors that use it regularly and they are all radiologists. My doctor, who is an oncologists uses it daily, but if he sees something suspicious always send his patients to Dr Bahn. He said that flatly Dr Bahn is much better than he is and that he just doesn't want to get involved in giving biopsies and taking flack from the urological community. When it comes to PC there are a lot of turf wars that we patients are not aware of and are not doing us any good. If I ever had a reoccurrance I would get another CDU in order to attempt to define if it is a local reoccurrance.
I would never start a program of Active Surviellance without getting a CDU as a baseline to monitor tumor growth. If I were considering surgery I would get a CDU in order to identify the tumor location to evaluate the probability of a successful outcome. I would never get a biopsy unless it was CDU guided. All this I learned on my own with quite a bit of resistance from by urologists. I think there is compelling evidence that CDU, in the hands of a skilled radiologist, is a useful tool in helping identify and stage PC.
JT
 
 
 

compiler
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Date Joined Nov 2009
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   Posted 11/22/2010 12:59 PM (GMT -6)   
John T:
 
Thanks for taking the time to write such a complete response.
 
You did confirm my thinking that this is far from the mainstream and you gave some possible reasons why this is true. If this were truly superior I would hope that at least major centers would invest in it and use it (they could charge more for the latest and greatest). But you make a good point regarding a turf war between urologists and radiologists on this issue.
 
It's very interesting. While I have no doubt whatsoever that in your case a CDU was the better choice, have there been many studies comparing the CDU with the more typical modalities? It seems there is always good anecdotal data for a particular diagnostic or treatment modality.
 
This is where I have difficulty with some of the alternative methods (particularly diet supplements). There seems to be a paucity of studies confirming one method as better than another. In fact, with supplements, we find one study says yippeee it's great and another study says forget it.
 
Anyway, I am not lumping CDU in with supplements!
 
Question: I've already had my prostate removed. Is there any role left for me regarding CDU? Would it come in handy in considering SRT?
 
Mel

John T
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Date Joined Nov 2008
Total Posts : 3730
   Posted 11/22/2010 3:52 PM (GMT -6)   
Mel,
I have seen about 5 or 6 studies on CDU and they are mixed. Some showing a significant difference and others showing no difference. I don't think any skill or experience was factored in and I would expect that the true masters would have gotten much better results.
I saw a presentation by Dr Bahn in which he identified a localized reoccurrance after a failed surgery. You might want to contact him or Dr Lee in your neck of the woods to see if this is of any value. If you are going to have SRT anyway it may be of little value, but if one was considering a choice between SRT and HT it would be a good thing to know if it is localized. For SRT it would also be valuable to know whether to radiate just the bed or the pelvic lymphnodes along with the bed.
JT
65 years old, rising psa for 10 years from 4 to 40; 12 biopsies and MRIS all negative. Oct 2009 DXed with G6 <5%. Color Doppler biopsy found 2.5 cm G4+3. Combidex clear. Seeds and IMRT, no side affects and psa .1 at 1.5 years.

John T
Veteran Member


Date Joined Nov 2008
Total Posts : 3730
   Posted 11/22/2010 3:53 PM (GMT -6)   
Mel,
I have seen about 5 or 6 studies on CDU and they are mixed. Some showing a significant difference and others showing no difference. I don't think any skill or experience was factored in and I would expect that the true masters would have gotten much better results.
I saw a presentation by Dr Bahn in which he identified a localized reoccurrance after a failed surgery. You might want to contact him or Dr Lee in your neck of the woods to see if this is of any value. If you are going to have SRT anyway it may be of little value, but if one was considering a choice between SRT and HT it would be a good thing to know if it is localized. For SRT it would also be valuable to know whether to radiate just the bed or the pelvic lymphnodes along with the bed.
JT
65 years old, rising psa for 10 years from 4 to 40; 12 biopsies and MRIS all negative. Oct 2009 DXed with G6 <5%. Color Doppler biopsy found 2.5 cm G4+3. Combidex clear. Seeds and IMRT, no side affects and psa .1 at 1.5 years.
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